Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.
Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article provided whatever detail I could find on the costs of poor communications and data exchange among health care providers. But in truth, it’s hard to imagine the toll taken by communications failures beyond certain obvious consequences, such as repeated tests and avoidable medical errors. One has to think about how the field operates and what we would be capable of with proper use of data.

As patients move from PCP to specialist, from hospital to rehab facility, and from district to district, their providers need not only discharge summaries but intensive coordination to prevent relapses. Our doctors are great at fixing a diabetic episode or heart-related event. Where we fall down is on getting the patient the continued care she needs, ensuring she obtains and ingests her medication, and encouraging her to make the substantial life-style changes that can prevent reoccurrences. Modern health really is all about collaboration–but doctors are decades behind the times.

Clinicians were largely unprepared to handle the new patients brought to them by the Affordable Care Act. Examining the impact of new enrollees, who “have higher rates of disease and received significantly more medical care,” an industry spokesperson said, “The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time…Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.” Just where the health providers fall short.

One care practice drastically lowered ER admissions through a notably low-tech policy–refering their patients to a clinic for follow-up care. This is only the beginning of what we could achieve. If modern communications were in place, hospitals would be linked so that a CDC warning could go to all of them instantly. And if clinicians and their record systems were set up to handle patient-generated data, they could discover a lot more about the patients and monitor behavior change.

How are the hospitals and clinics responding to this crisis and the public pressure to shape up? They push back as if it was not their problem. They claim they are moving toward better information sharing and teamwork, but never get there.

One of their favorite gambits is to ask the government to reward them for achieving interoperability 90 days out of the year. They make this request with no groveling, no tears of shame, no admission that they have failed in their responsibility to meet reasonable goals set seven years ago. If I delivered my projects only 25% of the time, I’d have trouble justifying myself to my employer, especially if I received my compensation plan seven years ago. Could the medical industry imagine that it owes us a modicum of effort?

Robert Schultz, a writer and entrepreneur in health care, says, “Underlying the broken communications model is a lack of empathy for the ultimate person affected–the patient. Health care is one of the few industries where the user is not necessarily the party paying for the product or service. Electronic health records and health information exchanges are designed around the insurance companies, accountable care organizations, or providers, instead of around understanding the challenges and obstacles that patients face on a daily basis. (There are so many!) The innovators who understand the role of the patient in this new accountable care climate will be winners. Those who suffer from the burden of legacy will continue to see the same problems and will become eclipsed by other organizations who can sustain patient engagement and prove value within accountable care contracts.”

Alternative factors

Of course, after such a provocative accusation, I should consider the other contributors that are often blamed for increasing health care costs.

An aging population

Older people have more chronic diseases, a trend that is straining health care systems from Cuba to Japan. This demographic reality makes intelligent data use even more important: remote monitoring for chronic conditions, graceful care transitions, and patient coordination.

The rising cost of drugs

Dramatically increasing drug prices are certainly straining our payment systems. Doctors who took research seriously could be pushing back against patient requests for drugs that work more often in TV ads than in real life. Doctors could look at holistic pain treatments such as yoga and biofeedback, instead of launching the worst opiate addiction crisis America has ever had.

Government bureaucracy

This seems to be a condition of life we need to deal with, like death and taxes. True, the Centers for Medicare & Medicaid Services (CMS) keeps adding requirements for data to report. But much of it could be automated if clinical settings adopted modern programming practices. Furthermore, this data appears to be a burden only because it isn’t exploited. Most of it is quite useful, and it just takes agile organizations to query it.

Intermediaries

Reflecting the Byzantine complexity of our payment systems, a huge number of middlemen–pharmacy benefits managers, medical billing clearinghouses, even the insurers themselves–enter the system, each taking its cut of the profits. Single-payer insurance has long been touted as a solution, but I’d rather push for better and cheaper treatments than attack the politically entrenched payment system.

Under-funded public health

Poverty, pollution, stress, and other external factors have huge impacts on health. This problem isn’t about clinicians, of course, it’s about all of us. But clinicians could be doing more to document these and intervene to improve them.

Clinicians like to point to barriers in their way of adopting information-based reforms, and tell us to tolerate the pace of change. But like the rising seas of climate change, the bite of health care costs will not tolerate complacency. The hard part is that merely wagging fingers and imposing goals–the ONC’s primary interventions–will not produce change. I think that reform will happen in pockets throughout the industry–such as the self-insured employers covered in a recent article–and eventually force incumbents to evolve or die.

The precision medicine initiative, and numerous databases being built up around the country with public health data, may contribute to a breakthrough by showing us the true quality of different types of care, and helping us reward clinicians fairly for treating patients of varying needs and risk. The FHIR standard may bring electronic health records in line. Analytics, currently a luxury available only to major health conglomerates, will become more commoditized and reach other providers.

But clinicians also have to do their part, and start acting like the future is here now. Those who make a priority of data sharing and communication will set themselves up for success long-term.